对某核电厂主给水丧失手动停堆后操纵员人因失误的根本原因分析

The Root Cause Analysis of the Operator’s Human Error after Reactor Manual Shutdown Due to Loss of the Main Feed-water

某AP1000型核电厂在主给水丧失手动停堆后S信号自动触发,在恢复机组状态期间操纵员人因失误多次导致安全系统动作,并出现了堆芯出口过冷度低于0℃的情况。本文运用事件原因因素图(ECF)和因果分析法对该事件进行了根本原因分析。通过梳理事件序列,确定了事件发展过程中的失效点,通过对各失效点的深入分析,得出事件的根本原因为营运单位对工作计划或过程的有效性监督不够和应急运行规程不完善,并提出针对性的改进建议。

In an AP1000 nuclear power plant,the S signal automatically actuated after reactor manual shutdown due to loss of the main feed-water.during the restoration of the unit state,The AP1000 safety system was activated several times because of the operator’s human error,and the super-cooling degree of the core outlet was lower than0℃.the root cause was analyzed by using the Event and Cause Factor(ECF)chart and Causal Analysis method.the sequence of event was sorted out to determine the failure points of the event process.Through the in-depth analysis of the failure points,the root cause of the event is that the license has insufficient supervision of the effectiveness of the work plan or process and the incomplete emergency operation procedures,and an optimization proposal was given for this cause.